Homeless and Health2018 Fall Health Seminar

November 29, 2018Presented by The Wellness Coalition in

partnership with Medical Advocacy & Outreach

Cynthia Bisbee, Ph.D.C.C. Bisbee and Associates, LLC

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TopicsWho are people experiencing

homelessness?What health concerns do people

experiencing homelessness have?What resources are available for

helping people experiencinghomelessness to access health careHow can we help people become

healthier?2

“Health and homelessness areintricately linked. Health problems cancause a person’s homelessness as wellas be exacerbated by the experience.”

National Alliance to End Homelessness, 2017

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Who Are the PeopleExperiencing Homelessness?

Different agencies use differentdefinitions of homelessness, whichaffect how various programs determineeligibility for individuals and families atthe state and local level. Health centersuse the HHS definition in providingservices.

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Who Are the PeopleExperiencing Homelessness?

There is more than one “official” definitionof homelessness:HRSA: A homeless individual is defined in

section 330(h)(5)(A) as “an individual who lackshousing (without regard to whether theindividual is a member of a family), including anindividual whose primary residence during thenight is a supervised public or private facility(e.g., shelters) that provides temporary livingaccommodations, and an individual who is aresident in transitional housing.”

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Who Are the PeopleExperiencing Homelessness?

HRSA: An individual may be consideredto be homeless if that person is“doubled up,” a term that refers to asituation where individuals are unable tomaintain their housing situation and areforced to stay with a series of friendsand/or extended family members.

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Who Are the PeopleExperiencing Homelessness?

Programs funded by the U.S.Department of Housing and UrbanDevelopment (HUD) use a different,more limited definition of homelessness[found in the Homeless EmergencyAssistance and Rapid Transition toHousing Act]

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Who Are the PeopleExperiencing Homelessness?

HUD Definition:• An individual or family who lacks a

fixed, regular and adequate nighttimeresidence

• Place not used for sleeping for humanbeings

• Shelter for temporary livingarrangements

• Exiting an institution, came from shelteror street 8

Who Are the PeopleExperiencing Homelessness?

Imminently losing nighttime residenceWithin 14 daysNo subsequent residence identifiedLacks resources to obtain permanent housing

Unaccompanied youth under 25 or family withchildrenMeet homelessness criteria for other government

programsNo housing past 60 daysTwo or more moves during past 60 daysExpected to continue due to chronic conditions

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Who Are the PeopleExperiencing Homelessness?

Fleeing domestic violenceLife-threatening conditions in primary

nighttime residenceNo other residenceLacks resources to obtain permanent

housing

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Myths about the HomelessThey are mostly single menThey are from someplace elseBeing homeless is a lifestyle choiceHomeless people commit more violent

crimes than housed peopleHomeless people don’t workAll have mental illness or abuse

substances11

Reasons for Homelessness

Lack of affordable housingPovertyUnemploymentMental Illness (about 20%)*Substance abuse (about 16%)*Domestic violenceLack of community supports*National Alliance to End Homelessness, 2017

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Health Care Problemsof Homeless Persons

Illnesses associated with povertyConditions associated with exposureChronic diseasesMental illness &/or alcohol/drug addictionNo incomeNo insuranceNo transportation

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Geographic / transportation barriersNo resources to travel to access health

care

High rates of poverty & unemploymentNo income to pay for health care

Little or no health insuranceHealth disparitiesHigher rates of disease and disability in

homeless

High rates of chronic conditions

Health Care Access Issues forMontgomery’s Homeless

River RegionHealth Care for the Homeless

Needs AssessmentMontgomery Area Community Wellness Coalition 2009-2010

RRHCC Health Care Access SurveySheltered HomelessUnsheltered Homeless211 Connects Callers

MACH Annual Homeless EnumerationFocus groups

Health Care Access SurveyEnvision 2020 & The Wellness Coalition

Survey ProcessProject Goal: “A medical home for

everyone in the River RegionSurvey measured factors affecting access

to medical care / medical homeThree PopulationsPeople Seeking Social ServicesPublic Housing ResidentsSheltered & Unsheltered Homeless

Health Care Access SurveySummary of Findings

53% Female40% Age 26-3577% African-American97% Non-Hispanic77% Unemployed57% Have a disability57% Have no health insurance41% Can get health care only “sometimes”44% Said they can’t afford it41% Use the ER for their primary care 17

Chronic Conditions of the Homeless Populationin the River Region

29% have high blood pressure 24% have a mental illness

17% have asthma 11% have diabetes

8% have heart disease 8% have obesity

2% have COPD 6% listed another condition

Source: Wellness Coalition Health Care Survey, 2010

MACH 2018 Point in TimeHomeless Enumeration

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Sheltered Unsheltered TotalHouseholds with atleast one Adult andone Child 97 0 97

Persons inHouseholds with onlyChildren 5 0 5

Persons inHouseholds withoutChildren 194 69 263

Total 296 69 365

Montgomery Annual HomelessEnumeration - Health Problems

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Health Problems Sheltered Unsheltered

Disability 29% 21%

Health Problem 24% 28%Mental Health Problem 64% 24%

HIV/AIDS 4% 1%

Alcohol/Drug Problem 37% 36%

Montgomery Annual HomelessEnumeration - Health Care Needs

Needs Sheltered UnshelteredMedical Care 20% 26%Medication 14% 17%Dental Care 28% 47%Substance Abuse Help 10% 31%Mental Health Help 17% 9%

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HomelessHealth Care Access Survey

Surveyed homeless persons about Access to healthcare In shelters On the street Through 211 calls

37% have a chronic condition 48% have a disability 64% have no insurance 29% never able to access health care 42% cannot afford health care 42% receive their care in the emergency room

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Focus Group DemographicsHeld at 9 different locationsSheltersStreet

Most frequent zip codes36108 (29%)36111 (14%)36104 (10%36092 (10%)36116 (7%)

Focus Group DemographicsMost frequent age groups51 - 55 (18%)56 - 60 (16%)46 – 50 (11%)26 – 30 (8%)31 – 35 (8%)75 – 80 (8%)

Gender67% Male33% Female

Focus Group DemographicsMost frequent age groups51 - 55 (18%)56 - 60 (16%)46 – 50 (11%)26 – 30 (8%)31 – 35 (8%)75 – 80 (8%)

Gender67% Male33% Female

Health ConditionsMental illness 27 31.4

Obesity 21 24.4

Heart problems 12 14.0

Diabetes 11 12.8

Spinal problems 6 7.0

Other (unspecified) 4 4.7

Asthma 3 3.5

Liver/kidney/blood 2 2.3

Total 86 100.0

Places Where AccessHealth Care

Emergencyroom/emergencydepartment (7)Clinics/Lister Hill (7)Health Department (4)Pri Med (2)Private doctor (2)Medical Outreach (2)VA (2)

Jackson HospitalWal-Mart (over the

counter drugs)Catholic Social

ServicesDentist (but won’t

take Medicaid)No insuranceNo money, can’t go

Health Care Challenges Co-pay/co-pay required (3) Medicine (paying for medicine)/getting prescriptions

filled/cost of prescriptions (3) Sooner appointment availability Higher wait for patients with no insurance How you’ll be treated How to reach doctors when calling Automated voice systems Lack of providers on staff Getting care Minimize the need for care Referral expectations Not having documents need to apply for financial

assistance

Health Care Challenges• Qualifying for government assistance• Personal fears/phobias of health concerns• What the doctors may tell you/health issues• Transportation/transportation issues (6)• Cost/money/choices between healthcare and life

needs/affordability (5)• Waiting in line/how long it takes to see doctor/getting

in to be seen on same day/long waits/unable to seedoctor (5)

• Insurance coverage/no insurance/not knowing whatinsurance covers (4)

• Whether doctor will give correct diagnosis/having acompetent doctor/thorough doctor/having a

• doctor that listens (4)

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Barriers to AccessingHealth Care

No money for health careLittle or no health insuranceLack of information about treatment

optionsTransportation issuesLack of knowledge about diseaseLack of social support system

Changes Desired in Health Care

No co-pay/no bills/free medical/dental care (5) Don’t have to wait to see doctor/less wait/quicker

appointments (3) Free transportation (3) Available when patients need it/assistance with needs

any time (2)One stop care/healthcare that includes everything (3)No insurance required (2) Affordable fee schedule/affordable (2) Friendly atmosphere/empathetic staff/nurses (2)

Changes Desired in Health Care Competent medical staff/thorough doctors/right

diagnosis (3) Trustworthy medications/research medications

before prescribing Prescription delivery Free meds Use of the Lister Hill model Universal insurance Individual fee scales Easy to get to Fewer government regulations

Changes Desired in Health Care

Clean environmentFree medical alert braceletCease insurance discriminationChildcare in waiting rooms/emergency roomsNo shots

Other Health Care Needs

Need healthcare nowMedicare information Healthcare for my children Give Ensure/vitamins to people to provide them with

nutrientsMore mental health services Food stamps, nutrition for the homeless to remain

healthy Law enforcement give announcement listing everyone

with HIV/AIDS

Other Health Care Needs Transportation (4)More clinics in low-income neighborhoods/more

services (3) To be treated with respect (2)More information about resources available (2) Dental specialist/dental care (2) Fee clinics Help in getting insurance Lower cost medicine Free pap smears, mammograms, and prostate checks

Other Needs

Free mobile services in drug-infestedareasFree methadone clinicsNeedle exchangeDrug screen facility staffMoneyClothesSS Identification

Other Needs

Free places to wash clothes, bathe, etc.Investigate SSI abuseEmploymentHousing for the homelessTORT immunity and reformCase management

A Model for ProvidingHealth Care for the

Homeless

Health Services, Inc.

Located in Montgomery Area Mental HealthAuthority facility (space donated by MAMHA)Operates 3 days per week 7:30 am-4:30 pmStaffed by a provider (nurse practitioner), nurses

registration staff, wellness case manager, andother staff as needed (x-ray, lab, etc.)Serves homeless, MAMHA clients, and any other

person who wishes to receive services thereProvides basic primary care, referral for specialty

care, and wellness case management

Fixed Clinic

Trailer pulled by pick-up truckOperates 2 days per week 8:30 am-3:30

pmStaffed by a provider (nurse practitioner),

registration staff, wellness case manager,and other staff as needed (x-ray, lab, etc.)Travels on a schedule to homeless shelters

in MontgomeryServes shelter residents and others in the

areaUses shelter as waiting area

Mobile Clinic

~ HSI Mobile Health Clinic Schedule ~ December 2018~S M T W Th F S2 3 4

8 AM – 3 PMJuliet Hampton Morgan Library

245 High Street

5 68 AM – Lighthouse Counseling Ctr

111 Coliseum Blvd

7 8

9 10 118 AM – Salvation Army

900 Maxwell Blvd1 PM – Nellie Burge& Family Promise1226 Clay Street

12 138 AM Gibbs Village East

(Public Housing Authority)1701 Terminal Road

1 PM – Friendship Mission North – 312Chisholm St

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16 17 188 AM – 3 PMSmiley Court

(Public Housing Authority)4107 Marlyn Street

19 208 AM – AID to Inmate Mothers

660 Morgan Avenue1 PM Gibbs Village East

(Public Housing Authority)1701 Terminal Road

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23 24 258 AM – 3 PMSmiley Court

(Public Housing Authority)4107 Marlyn Street

26 278 AM – Governor’s Square Library

2885 E South BlvdMt Gillard Baptist Church

3323 Day Street

28 29

30 31 1 2 3 4 5

Montgomery Area CommunityWellness Coalition

Coalition of safety net providers Baptist Health Community Hospital Community-at-Large Representative (CPA) Community Care Network Family Guidance Center of Alabama, Inc. Health Services, Inc. Jackson Hospital & Clinic, Inc. Joint Public Charity Hospital Board Medical Outreach Ministries Mid-Alabama Coalition for the Homeless Montgomery Area Mental Health Authority, Inc. Montgomery County Health Department Public Health Area 8

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Interventions for ChronicDisease Management

Adopting a healthy lifestyleTobacco avoidanceGood nutritionRegular physical activity

Using a “Medical Home”Accessing Mainstream BenefitsDisease Self-Management Education

Wellness Case ManagementLiaison to shelters for scheduling patientsAssisting patients with accessing free

medicationsLocal resourcesPharmaceutical company patient assistance

programsAssistance with application for health insuranceHealth insurance marketplaceMedicaid

Chronic disease self-management education

Lessons Learned inWelcoming the Homeless

Be lenient in expecting them to conform toclinic appointment requirementsBe respectful of their lack of transportationRealize they are not homeless by choiceThey may have multiple problemsMost will have no way to pay for servicesSpecial arrangements for follow-up such as

through shelter contacts

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Working with PersonsWho Have Mental Illness

DO Remain calm Take your time Be respectful Be supportive Express desire to help Continually assess the

situation Ask others causing

agitation to leave area

DO Be supportiveOne person communicate

with the person Focus on situation/

behavior not the person Give clear directions

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Working with PersonsWho Have Mental Illness

DO NOTLose your composureGet excitedAct in angerChallenge the personArgueThreatenDeceive the person

DO NOTAgree or disagree

with delusionsRidiculeTease or jokeWhisper to othersTouch

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Resources

www.wellness-coalition.org

http://nationalhomeless.org

National Health Care for the HomelessCoalition

National Alliance to End Homelessness

Survey Results

Race77% African-American21% Caucasian2% Other

Ethnic Origin3% Hispanic Origin97% Non-Hispanic Origin

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Survey Results

Gender47% Male53% Female

Age1% Under 1840% age 18-3532% age 36-4926% age 50-642% age 65+

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Survey ResultsEmployment Status12% Full Time10% Part Time77% Unemployed

Reasons Unemployed1% Retired21% Laid Off37% Disabled41% Other Reason

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Survey ResultsPresence of Chronic Condition 38% Chronic Condition 62% No Chronic Condition

Type of Chronic Condition 28% Mental Illness 26% High blood Pressure 13% Asthma 10% Diabetes 8% Obesity 7% Other 4% Heart Disease 2% COPD

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Survey Results Ability to Get Medical Care 41% Sometimes 38% Always 21% Never

Reasons Cannot Get Medical Care 44% Can’t Afford It 21% No Doctor 19% No Transportation 19% Use Home Remedy 10% Other

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Survey Results

Presence of Disability57% Yes43% No

Type of Insurance57% None26% Medicaid10% Medicare2% Blue Cross6% Other

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Survey Results Location of Main Health Care Provider 41% Emergency Room 35% Clinic 18% Private Office 5% Other 1% Urgent Care

Times Gone for Medical Care Last 12 Months 18% None 28% 1-2 Times 21% 3-4 Times 20% 5-6 Times 14%Once a Month

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Survey ResultsTransportation to Medical Appointments12% Walk31% Car2% Taxi27% Bus6% Private Shuttle23% Family21% Friend9% Pay Someone2% Call 211 57